GW1-2021-01531_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD l F pal Use ONLY:
This form can be used for single or multiple wells ", i IJ
1.Well Contractor Information:
KOLBY MITCHELL SAWYERS 9 '- T�Rzoivr
N1 �..
TO DESCRIPTTON
Well Contractor Name U it ft
4471-A Intorrnatlon Pro ctlon fl ft
wR
NC Well Contractor Certification Number p ..-1 ..(3 U[ -CAS G.foriFuha casedweits.01tE1Nt i1.Ifs ltcablf
FROM TO DIAMETER TATCKNF.SS 11fATERi.4I.
CLYDE SAWYERS AND SON WELL +1 ft. 64 ft.
6.25 In #21 1 PVC
Company Name
1 ,1}Vj±7BR CiCSIlG.OR,CtJBIit(i ""eutherniifE;stirsed 1aa
20120114082 FROM DIAMKTKR THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): s.,:.<........
17.SCRBEi�t..,.. ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE TFUCKNESS MATERIAL
Ct. ft, in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single)
❑IndusriaUCommercial ❑Residential Water Supply(shared) 1lt:GfibB3-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft• 20 ft' BENTONITE PUMPED
Non-Water Supply Well:
❑Monitoring ❑Recovery
injection Well: tit. ft.
.
[]Aquifer Recharge ❑Groundwater Remediation 18.=SiNA1GRtk33ACdf d:a' `eatile ...- .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EDIPLACEMENi METHOD
ft. it.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
i 20:-1)$1LL11�1<�:1' G-attaetia11111tturtalslte¢is3taiecessaev
._..
❑Geothermal(Closed loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock tv a rain size,etc.)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 64 ff• OVER BURDEN
ft. ft.
4.Date Well(s)Completed: 02/16/2021 Well ID#
64 fL 405 ft• GRANITE
5a.Well Location:
Kimzey Mills, INC fL ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
165 Shep Dr., Mills River, Lot # 8 ft. ft.
Physical Address,City,and Zip 21,:3tEMARK9.:, ...
Henderson 9621969718
County Pastel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N w 02-18-2021
log PE 40E-
Signs citified Well Contras Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this fin-, /hereby c fJ that the well(s)ww(were)constructed in aceutvhtnre
with ISA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: E)Yes or ❑No copy of ilis record has been provided to the well oisner.
If this is a repair.fill out knuur x•ell construction infarmation and explain the nature of the
repair tinder#21 remarks section or on the back ofthis jurm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'e4fferew(example-AV00'and 2(a100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
ff water level is above casing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the addl'ess in
ROTARY AIR 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 3 Method of test- RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount• 20 well construction to the county health department of the coun where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013